Ver el código de «Marginal ulcer»

==Background==
*Marginal ulcer (also called stomal ulcer or anastomotic ulcer) is a mucosal ulceration that develops at or near a surgical gastroenteric anastomosis, most commonly on the jejunal side of the gastrojejunostomy after [[Roux-en-Y gastric bypass]] (RYGB).<ref>Coblijn UK, Goucham AB, Lagarde SM, Kuiken SD, van Wagensveld BA.
*Development of ulcer disease after Roux-en-Y gastric bypass, incidence, risk factors, and patient presentation: a systematic review. ''Obes Surg''. 2014;24(2):299-309.</ref>
*It is the most common late complication of RYGB and may present to the emergency department with pain, [[GI bleeding]], or perforation.


* Incidence ranges from 0.6% to 25% following RYGB, with a mean prevalence of approximately 4.6%<ref>Azagury DE, Abu Dayyeh BK, Greenwalt IT, Thompson CC. Marginal ulceration after Roux-en-Y gastric bypass surgery: characteristics, risk factors, treatment, and outcomes. ''Endoscopy''. 2011;43(11):950-954.</ref>
* Typically presents a median of 1-2 years after surgery, but can occur from weeks to >10 years postoperatively
* Ulcers are located on the anastomosis (~50%) or the jejunal mucosa (~40%)
* Pathophysiology is multifactorial:
** Acid exposure — jejunal mucosa lacks protective buffering mechanisms against gastric acid
** Ischemia — tension on the anastomosis, compromised local blood supply
** Large gastric pouch — greater parietal cell mass increases acid production<ref>Edholm D, Ottosson J, Sundbom M. Importance of pouch size in laparoscopic Roux-en-Y gastric bypass: a cohort study of 14,168 patients. ''Surg Endosc''. 2016;30(5):2011-2015.</ref>
** Foreign body reaction — non-absorbable suture material or exposed staples at the anastomosis
** Gastrogastric fistula — allows acid from the excluded gastric remnant to reach the pouch
* Risk factors (by meta-analysis):<ref>Liang Y, Wang C, Yang L, et al. Nonsurgical risk factors for marginal ulcer following Roux-en-Y gastric bypass for obesity: a systematic review and meta-analysis of 14 cohort studies. ''Int J Surg''. 2024;110(3):1793-1799.</ref>
** [[Helicobacter pylori]] infection (OR 4.97)
** Smoking (OR 2.50)
** Diabetes mellitus (OR 1.80)
** [[NSAID]] / [[aspirin]] use
** [[Corticosteroid]] use
** History of [[peptic ulcer disease]]
** [[Alcohol]] use
** SSRI use (proposed mechanism: impaired mucosal healing)

==Clinical Features==
* Epigastric or periumbilical pain (most common, ~63%)<ref>Azagury DE, Abu Dayyeh BK, Greenwalt IT, Thompson CC. Marginal ulceration after Roux-en-Y gastric bypass surgery: characteristics, risk factors, treatment, and outcomes. ''Endoscopy''. 2011;43(11):950-954.</ref>
** Often postprandial, may mimic pre-bypass [[peptic ulcer disease]]
* Nausea and vomiting
* Reduced oral intake / early satiety
* [[GI bleeding]] (~24%)
** [[Melena]], [[hematemesis]], or occult blood loss with iron deficiency [[anemia]]
* [[Dysphagia]] (if associated anastomotic stricture)
* Complicated presentations:
** Perforation — acute-onset severe abdominal pain, peritoneal signs, [[sepsis]]
*** May present with left shoulder pain (diaphragmatic irritation)
** Hemorrhage — [[Hemorrhagic shock|hemodynamic instability]], [[hematemesis]], [[hematochezia]]
** Stricture — progressive [[dysphagia]], vomiting, inability to tolerate oral intake
** Gastrogastric fistula — chronic symptoms, weight regain
* Up to 28% of patients may be '''asymptomatic''' (discovered incidentally on surveillance endoscopy)

==Differential Diagnosis==
{{Abdominal Pain DDX Diffuse }}
* [[Peptic ulcer disease]]
* [[Anastomotic leak]] (early postoperative period)
* [[Anastomotic stricture]]
* [[Internal hernia]] (post-bariatric)
* [[Small bowel obstruction]]
* [[Cholelithiasis]] / [[cholecystitis]] (common after rapid weight loss)
* [[Pancreatitis]]
* [[Mesenteric ischemia]]
* [[Gastrogastric fistula]]
* [[Gastritis]]

==Evaluation==

===Workup===
* Labs:
** [[CBC]] — anemia (chronic blood loss), leukocytosis (perforation/infection)
** [[BMP]] — electrolyte abnormalities from vomiting or poor oral intake
** [[Lipase]] — rule out [[pancreatitis]]
** [[Lactate]] — if concern for perforation or ischemia
** [[Type and screen]] — if GI bleeding
** [[H. pylori]] testing (stool antigen or urea breath test preferred over serology post-bypass)
** [[Iron studies]] — if chronic anemia
* Imaging:
** CT abdomen/pelvis with IV contrast — study of choice in the ED for suspected complications<ref>Meissnitzer MW, Stättner S, Gmeiner D, et al. Imaging features of marginal ulcers on multidetector CT. ''Clin Radiol''. 2023;78(2):e178-e185.</ref>
*** May show: wall thickening at the gastrojejunostomy, periananastomotic fat stranding, extraluminal air (perforation), extraluminal fluid, oral contrast leak
*** CT also evaluates for [[internal hernia]], [[small bowel obstruction]], and [[abscess]]
** Upright CXR or left lateral decubitus — may show free air under diaphragm if perforation
** UGI fluoroscopy with water-soluble contrast — can confirm contained perforation vs free leak
* EGD (esophagogastroduodenoscopy):
** Gold standard for diagnosis
** Directly visualizes ulcer at or near gastrojejunostomy
** Evaluates for exposed suture/staple material, gastrogastric fistula, stricture
** Allows biopsy (rule out malignancy, test for ''H. pylori'')
** Enables therapeutic intervention (hemostasis, dilation)
** May not be immediately available in the ED setting

===Diagnosis===
* Suspect in '''any post-bariatric surgery patient''' presenting with epigastric pain, GI bleeding, or signs of perforation
* Definitive diagnosis by EGD with direct visualization of ulcer at the gastrojejunal anastomosis
* CT findings suggestive but not diagnostic; primarily used to identify complications (perforation, abscess, obstruction)
* Visible suture material or staples at the ulcer base is a characteristic finding

==Management==

===Medical management (uncomplicated)===
* [[Proton pump inhibitor]] (PPI) — mainstay of treatment<ref>Pyke O, Yang J, Cohn T, et al. Marginal ulcer continues to be a major source of morbidity over time following gastric bypass. ''Surg Endosc''. 2019;33(10):3451-3456.</ref>
** High-dose PPI (e.g., [[omeprazole]] 40 mg BID or [[pantoprazole]] 40 mg BID)
** Duration: minimum 8-12 weeks; many patients require long-term or indefinite PPI
* [[Sucralfate]] 1 g QID (mucosal protectant, adjunct to PPI)
* Risk factor modification:
** Smoking cessation (critical)
** Discontinue [[NSAID|NSAIDs]], [[aspirin]] (if possible; discuss with prescribing physician)
** Limit [[alcohol]]
** ''H. pylori'' eradication if positive<ref>Schulman AR, Abougergi MS, Thompson CC. H. pylori as a predictor of marginal ulceration: a nationwide analysis. ''Obesity (Silver Spring)''. 2017;25(3):522-526.</ref>
** Optimize glycemic control in diabetics
** Discontinue or minimize corticosteroids
* Endoscopic removal of exposed foreign material (sutures, staples) if identified

===GI bleeding===
* Standard approach to [[Upper GI bleed]]
* Aggressive resuscitation, [[blood transfusion]] as needed
* IV PPI (e.g., [[pantoprazole]] 80 mg bolus then 8 mg/hr drip)
* Urgent EGD for diagnosis and hemostasis (clips, epinephrine injection, thermal therapy)
* Consult surgery if hemodynamically unstable or endoscopy fails to achieve hemostasis
* See [[Upper GI bleed]]

===Perforation===
* '''Surgical emergency''' in most cases
* NPO, IV fluid resuscitation, broad-spectrum [[antibiotics]]
* IV PPI
* Surgical options:<ref>Wendling MR, Linn JG, Keplinger KM, et al. Omental patch repair effectively treats perforated marginal ulcer following Roux-en-Y gastric bypass. ''Surg Endosc''. 2013;27(2):384-389.</ref>
** Omental (Graham) patch repair — most common initial approach
** Anastomotic revision with resection of ulcer bed
** Gastric bypass reversal (complex, reserved for refractory cases)
* Laparoscopic approach preferred if patient is hemodynamically stable and presents within 24 hours
* Contained perforation in select hemodynamically stable patients with minimal symptoms may be considered for non-operative management with NPO, IV antibiotics, and IV PPI (emerging evidence)<ref>Pope R, English W, Walden RL, et al. Non-operative approach to contained perforated marginal ulcers: a systematic review and case series. ''Am Surg''. 2024;90(3):471-477.</ref>

===Stricture===
* Endoscopic balloon dilation (may require serial dilations)
* Continue PPI therapy
* Surgical revision if refractory

==Disposition==
* Admit if:
** Signs of perforation or peritonitis → emergent surgical consultation
** Hemodynamically significant [[GI bleeding]]
** Inability to tolerate oral intake
** Severe pain requiring IV analgesia
** Concern for sepsis or abscess
* Discharge may be appropriate if:
** Mild symptoms with stable vital signs
** Tolerating oral intake
** Reliable follow-up arranged (PPI prescription, outpatient EGD referral, bariatric surgery follow-up)
** Clear return precautions given: worsening pain, vomiting, bloody or tarry stools, fever, lightheadedness
* Recurrence rate is high (~30% or more), especially if risk factors are not addressed<ref>Coblijn UK, Lagarde SM, de Castro SM, Kuiken SD, van Wagensveld BA. Symptomatic marginal ulcer disease after Roux-en-Y gastric bypass: incidence, risk factors and management. ''Obes Surg''. 2015;25(5):805-811.</ref>
* Approximately 9% of patients ultimately require surgical revision despite medical therapy
* Endoscopic surveillance is recommended given high recurrence rate

==See Also==
* [[Peptic ulcer disease]]
* [[Upper GI bleed]]
* [[Bariatric surgery complications]]
* [[Gastric bypass]]
* [[Small bowel obstruction]]
* [[Internal hernia]]
* [[Perforated gastric ulcer]]
* [[Helicobacter pylori]]

==External Links==
* [https://asmbs.org American Society for Metabolic and Bariatric Surgery (ASMBS)]

==References==
<references/>

[[Category:GI]]
[[Category:Surgery]]